Somehow on my 'week off' I'm busier than I would be if I were just going to work. How am I ever going to get my full Spellfire set or my next six million ISK?

(OK, nerd episode over).

I've been spurred into writing this post for two reasons - the first is this post of mine and the associated comments, the second is this article in the Financial Times. Two quick notes on the article, if the government want to employ a blog expert I can be had for a salary of, oh lets say £25,000+. Also if they want to invite me to talk to them, I'm more than happy to spill my brains the general direction of anyone in government.

To recap - the main target that the government has set ambulance services around the country is that of ORCON. This, at it's simplest, states that we should reach our high priority calls in under eight minutes and our medium priority calls in under fourteen minutes.

The problem that I have with this is twofold. Firstly, in a supposed 'evidence-based' NHS there is little clinical reason for the eight minutes as opposed to four minutes. Secondly, and much more importantly in my opinion it directly impacts on patient care.

In order to meet the eight minute target ambulance services are removing double-crewed ambulances from the road in order to increase the number of Fast Response Units (FRUs). The reasoning is that if an FRU is on scene then the 'clock stops' and the job is a success. It's not a success for the FRU if they are stuck on scene with a stabbing, unresponsive asthmatics or with a child with meningitis.

People who are seriously sick need to be in hospital, not having a solo responder holding their hand while praying in desperation for an ambulance.

Ambulance folk can do a lot to stabilise a patient, but as a trainer of mine wisely says, "the place for a sick patient isn't the back of an ambulance". Nor is it in their own home waiting for an ambulance to turn up.

So, what are we to do? We need to check on the performance of NHS trusts, that much is certain.

My solution is to have more targets.

But targets which will have an impact on patient care.

Lets have a target where we improve the number of heart attacks that we diagnose in the home and transfer to the 'gold standard' treatment centre. I think we are at 95-97% on that at the moment. How about improving the call to treatment time.

Lets have another target where we diagnose strokes (or 'brain attacks' in the jargon of today) and transport them to a specialist centre. Of course we might need a few more places to become specialist centres first, but isn't the NHS a 'joined up' organisation?

Lets have a target where we try to reduce the number of patients with asthma who need admitting to hospital. Better, lets reduce the number of people who need to stay in ITU because of asthma. Of course it isn't the sole job of the ambulance service to do this, but our targets should inform other aspects of the NHS, just as theirs affects ours.

How about improving the measurement and treatment of pain - its something that we aren't too good at, given that in most cases our choice of pain relief is restricted to entonox or morphine. We carry aspirin, but that is for heart attack treatment, not the treatment of minor pain. We also have paracetamol for children. How about nasal diamorphine? Improving the measurement and treatment of pain will directly improve patient's experiences.

How about improving cardiac arrest survival rates. We've managed to improve this greatly over the past few years and I'll be talking about this in a later post. Unfortunately the government doesn't 'reward' us due to our improvements in this area, perhaps they should.

Time until a patient is reached is important in some cases, so we'll keep a target for reaching patients, but lets change it to only having the clock stop when a proper double-crewed ambulance arrives on scene. The other targets (like cardiac arrest survival) will be met by FRUs getting there quickly, but this will mean that there is less chance of FRUs being manned at the expense of proper ambulances.

How about a target of increasing the amount of paramedic cover in an area. Or how about a target of improving the training of people on the road? Better trained staff means better care for patients.

Maybe a target to increase the number of ambulances on the road. Even better would be a target to have a certain amount of spare ambulances. Ambulances that are waiting for a call from a patient rather than the other way around. We should have a slight excess capacity of ambulances at all times, not have people waiting for ambulances to finish with one patient before they can be attended to.

Finally, how about a 'staff satisfaction' target - a happy workforce is a more effective workforce.

Some of these targets are more important than others and by giving individual targets a separate weighting we could come up with a total 'score' that will show improvement, but can also be broken down to show where further improvement can be made. For example the number of people who get diagnosed and treated at a specialist centre for a stroke could be worth ten times as much as the number of people who get painkillers for their broken arm.

We could even keep the ORCON target, but give it a more reasonable weighting of importance.

This system would have the advantage of being better based on current evidence and would highlight areas where changes can have an immediate effect on patient care and outcome.

There is a reason why I get a warm and fuzzy feeling when I diagnose and take to a specialist centre someone having a heart attack. It's because I've done something that will have an effect on the patients well-being. It's a feeling that I don't get when I reach somewhere in under eight minutes or meet an FRU who has been on scene for forty minutes.

Right - how do I get to be Minister In Charge of Sensible Ideas for Ambulances?

I've fiddled around a bit with this blog in an attempt to resolve some of the issues some people have had with getting a black screen when accessing the site. Let me know if it works out.

Ambulances may be spreading infections such as MRSA because they are not being cleaned properly, union leaders warn.

...At the other end of the scale London Ambulance Service has introduced on-site cleaners who work throughout the night to routinely deep clean the fleet. They also restock ambulances with fresh kit, freeing up paramedics for seeing patients. Effectively, crews bring in a dirty vehicle and leave with a cleaned one, Unison said.

It is pretty good in London to be completely honest. The 'Make-ready' crews do clean the ambulances and they do have an attempt at stocking the ambulances. Except when there isn't the spare kit on the station, in which case they don't run around to other stations to try and find the equipment, that's up to us.

We are also still supposed to check the ambulances, but this rarely happens (unless you come into work early) as our call rate is so high.

There are also random swabs of ambulances where we see if there is anything growing on an ambulance that shouldn't be there. So far the results have been very good.

It's especially good considering that the Make-ready people get paid minimum wage and work hours like 1am-5am.

Where it is somewhat let down is that due to the desire to have us rapidly 'turn around' at hospital, unless there is specific soiling of the ambulance (blood, vomit, or for me last night, large amounts of spittle) we don't have the time to clean down the trollies with detergent.

Nor do we have enough blankets to have each patient have their own separate one - again they only tend to get changed if there is visible soiling or if the patient is known to be carrying a communicable disease.

But on the whole I think that we do a pretty good job with the resources that we have - we could do better, but that would mean that the government would have to give us more money. Something that they are loathe to do.

An investigation has been launched after an ambulance took 22 minutes to reach a dying pensioner.
Ernie Rutkiewicz, 82, from Glasgow, choked on his dinner last Thursday and died in Glasgow Royal Infirmary.

The crew which attended could not be assigned to the emergency any earlier as they were on a meal break.

Under rules, ambulance crews are entitled to a half-hour break during their shift and cannot be disturbed during that period.

The meal break rule was introduced in Scotland as part of a UK-wide initiative called Agenda for Change, which affects NHS pay and conditions.

This is a sad story and I feel very sorry for the patient and his family.

Once more it is meal breaks that are 'to blame' for someone dying rather than there being a lack of ambulances to cover for the legally mandated rest breaks. The ambulance crew involved would not have even known about the call. For all intents and purposes during a rest break the crew are not being paid and are therefore not on duty.

(And it's a 'rest break', not a 'meal break', there is nothing making the employer provide an ability to eat food).

However, the last time I saw a story like this, the newspaper involved claimed that two ambulance crews were on a rest break - when actually their vehicles were broken and they were off the road waiting for them to be fixed.

I've just done four twelve hour shifts, I've only had one rest break on all those shifts. Most folks work eight hour days and would expect a break at some point.

My next set of shifts is eight hours long, and they are an absolute doddle considering our 'normal' shifts are twelve hours long.

I wonder if the investigation into this particular case will ask what other ambulances were doing? Were they covering GP who refuses to see patients? Were they rushing through the streets to a drunkard in the street? Were they going to someone who wanted an excuse to knock off work early? Where they running to someone who'd taken too much heroin? Were they trying to find a hoaxed call? Were they going to someone who just wasn't home?

It's too easy to suggest that the reason this man died was because of rest breaks as opposed to the much more complicated mixture of a lack of ambulances, too many inappropriate calls and that we are doing everyone else's job these days.

But that is less likely to 'sell' the news.